NR302 Final Exam
Subjective Data - Answer-What patient says about himself of herself during history taking
Objective Data - Answer-Observed when inspecting, percussing, palpating, and auscultating patient
during physical examination
Database - Answer-formed from above elements, plus patients record and laboratory studies
Steps of the Nursing Process - Answer-1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
Assessment - Answer--Review of clinical record
-interview
-health history
-physical exam
-functional assessment
-cultural and spiritual assessment
-consultation
-review of the literature
,Diagnosis - Answer--Interpretation of data by identifying clusters of cues so as to make inferences
-compare clusters of cues with definitions and defining characteristics
-validation of inferences based on findings
-identify related factors
-document the diagnosis
Outcome identification - Answer--identify expected outcomes related to patient individualization
-ensure outcomes are realistic and measurable
-specify short term and long term goal measurement criteria
Planning - Answer--Establish priorities on meeting identifies patient care goals
-develop outcomes and set time frames for meeting proposed outcomes
-identify relevant intervention and utilize interdisciplinary health care team members in the care
planning process for the patient
-document plan of care
Implementation - Answer--Determine patient readiness and involve pt
-review planned interventions with interdisciplinary health care team members to facilitate
collaborative effort
-utilize principles of delegation, being mindful of supervision and evaluation
-counsel person and significant others
-refer to continuing care
-document care provided
Evaluation - Answer--Refer to established outcomes
,-Evaluate individual's condition and compare actual outcomes with expected outcomes
-Summarize results of evaluation
-Identify reasons for failure to achieve expected outcomes
-Take corrective action to modify plan of care
-Document evaluation in plan of care
First level priority problems - Answer-Emergent, life threatening, and immediate
-airway
-breathing
-circulation
Second level priority problems - Answer-Next in urgency, requiring attention so as to avoid further
deterioration
-mental status changes
-acute pain
-infection risk
-abnormal lab values
-elimination problems
Third level priority problems - Answer-Important to patient's health but can be addressed after more
urgent problems are addressed
-lack of knowledge
-mobility problems
-family coping
Four types of Data - Answer-1. Complete total health database
, 2. focused or problem centered database
3. Follow up database
4. Emergency database
Complete total health database - Answer--Complete health history and full physical exam
-Describes current and past health state and forms baseline to measure all future changes
-yields diagnoses
Focused or problem centered database - Answer--for limited of short term problems
-collect "mini" database, smaller scope and more focused than complete database
-concerns mainly one problem, one cue complex, or one body system
-history and examination follow direction of presenting concern
Follow up data base - Answer-Status of all identified problems should be evaluated at regular and
appropriate intervals
-note changes that have occured
-evaluate whether problem is getting worse or better
-identify coping strategies being used
Emergency database - Answer--Rapid collection of data, often compiled concurrently with lifesaving
measures
-diagnosis must be rapid and comprehensive in nature
Describe rationale for providing culturally competent care. - Answer-Culturally competent implies that
the caregivers understand and attend to the total context of the patient's situation including awareness
of immigration status, stress factors, other social factors, and cultural similarities and differences.
Subjective Data - Answer-What patient says about himself of herself during history taking
Objective Data - Answer-Observed when inspecting, percussing, palpating, and auscultating patient
during physical examination
Database - Answer-formed from above elements, plus patients record and laboratory studies
Steps of the Nursing Process - Answer-1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
Assessment - Answer--Review of clinical record
-interview
-health history
-physical exam
-functional assessment
-cultural and spiritual assessment
-consultation
-review of the literature
,Diagnosis - Answer--Interpretation of data by identifying clusters of cues so as to make inferences
-compare clusters of cues with definitions and defining characteristics
-validation of inferences based on findings
-identify related factors
-document the diagnosis
Outcome identification - Answer--identify expected outcomes related to patient individualization
-ensure outcomes are realistic and measurable
-specify short term and long term goal measurement criteria
Planning - Answer--Establish priorities on meeting identifies patient care goals
-develop outcomes and set time frames for meeting proposed outcomes
-identify relevant intervention and utilize interdisciplinary health care team members in the care
planning process for the patient
-document plan of care
Implementation - Answer--Determine patient readiness and involve pt
-review planned interventions with interdisciplinary health care team members to facilitate
collaborative effort
-utilize principles of delegation, being mindful of supervision and evaluation
-counsel person and significant others
-refer to continuing care
-document care provided
Evaluation - Answer--Refer to established outcomes
,-Evaluate individual's condition and compare actual outcomes with expected outcomes
-Summarize results of evaluation
-Identify reasons for failure to achieve expected outcomes
-Take corrective action to modify plan of care
-Document evaluation in plan of care
First level priority problems - Answer-Emergent, life threatening, and immediate
-airway
-breathing
-circulation
Second level priority problems - Answer-Next in urgency, requiring attention so as to avoid further
deterioration
-mental status changes
-acute pain
-infection risk
-abnormal lab values
-elimination problems
Third level priority problems - Answer-Important to patient's health but can be addressed after more
urgent problems are addressed
-lack of knowledge
-mobility problems
-family coping
Four types of Data - Answer-1. Complete total health database
, 2. focused or problem centered database
3. Follow up database
4. Emergency database
Complete total health database - Answer--Complete health history and full physical exam
-Describes current and past health state and forms baseline to measure all future changes
-yields diagnoses
Focused or problem centered database - Answer--for limited of short term problems
-collect "mini" database, smaller scope and more focused than complete database
-concerns mainly one problem, one cue complex, or one body system
-history and examination follow direction of presenting concern
Follow up data base - Answer-Status of all identified problems should be evaluated at regular and
appropriate intervals
-note changes that have occured
-evaluate whether problem is getting worse or better
-identify coping strategies being used
Emergency database - Answer--Rapid collection of data, often compiled concurrently with lifesaving
measures
-diagnosis must be rapid and comprehensive in nature
Describe rationale for providing culturally competent care. - Answer-Culturally competent implies that
the caregivers understand and attend to the total context of the patient's situation including awareness
of immigration status, stress factors, other social factors, and cultural similarities and differences.
